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Neurogenic Bladder

October 2015. Neurogenic Bladder. Normal micturition. Normal micturition involves proper function of both bladder & urethra A detrusor of normal compliance & a physiologically competent urethral sphincter are both necessary to maintain urinary continence

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Neurogenic Bladder

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  1. October 2015 Neurogenic Bladder

  2. Normal micturition • Normal micturition involves proper function of both bladder & urethra • A detrusor of normal compliance & a physiologically competent urethral sphincter are both necessary to maintain urinary continence • Any increase in abdominal pressure, which inherently produces an increase in bladder pressure, is normally counteracted by an even greater increase in urethral pressure Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  3. Normal micturition • Normal micturition involves passive, low pressure filling of bladder during urine storage phase while voiding requires coordination of detrusor contraction with internal & external urinary sphincter relaxation • This micturition process is controlled by central nervous system, which coordinates sympathetic & parasympathetic nervous system activation with somatic nervous system to ensure normal micturition with urinary continence Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  4. Components of nervous system & neural pathways governing function of bladder Robert C. McDonough. HospitalPhysician. 2007; 14 Part1.

  5. Neurogenic bladder dysfunction • Voiding dysfunction can result from any mechanical or physiologic defects in micturition system  Inability of urinary sphincter to appropriately increase (or decrease) its pressure in response to increased bladder pressure • Damage or diseases of central, peripheral & autonomic nervous systems may result in neurogenic bladder dysfunction Neurogenic bladder dysfunction may complicate a variety of neurologic conditions Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  6. Neurogenic bladder can lead to… • Lower urinary tract infections • Urinary retention • Urinary tract obstructions • Upper urinary tract infections • Serious systemic illnesses including septicemia & acute renal failure • Neurogenic bladder with detrusor overactivity may cause incontinence, which not only leads to embarrassment, depression & social isolation but also may lead to skin decubiti, urethral erosions& upper urinary tract damage Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  7. Classification of Neurogenic Bladder • Many classifications have been used to group neurogenic bladder dysfunction • Each has their merits and clinical utility • These classifications may be based on urodynamic findings (e.g., Lapides, Krane & Siroky), neurourologic criteria (Hald and Bradley, Bors and Comarr), or on bladder & urethral function (International Continence Society, Wein Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  8. Classification (Madersbacher)

  9. Classification of Neurogenic Bladder • A popular classification of neurogenic bladder dysfunction based on location of neurologic lesion can help guide pharmacologic & surgical therapies, with voiding abnormalities seen clinically following from disruptions of normal urinary physiology • In this classification, neurogenic bladder arises from: • Lesions above pontine micturition center (e.g. stroke or brain tumor) producing uninhibited bladder • Lesions between pontine micturition center& sacral spinal cord (e.g., traumatic spinal cord injury or multiple sclerosis involving cervicothoracicspinal cord) producing an upper motor neuron bladder Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  10. Classification of Neurogenic Bladder • Sacral cord lesions that damage detrusor nucleus but spare pudendal nucleus producing a mixed type A bladder • Sacral cord lesions that spare detrusor nucleus but damage pudendal nucleus producing mixed type B bladder • Lower motor neuron bladder from sacral cord or sacral nerve root injuries Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  11. Anatomy & physiology of micturition with potential injury sites to urologic system Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  12. Uninhibited neurogenic bladder • In uninhibited neurogenic bladder dysfunction, there is usually reduced awareness of bladder fullness & a low capacity bladder due to reduction of inhibition of pontine micturition center (PMC) by cortical & subcortical structure damage • Urinary incontinence may occur with brain lesions occurring above pontine micturition center, especially with bilateral lesions • Since PMC is intact, normal opposition of detrusor & internal/external sphincter tonus is maintained so there are no high bladder pressures developed that can lead to upper urinary tract damage Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  13. Upper motor neuron neurogenic bladder dysfunction • Upper motor neuron neurogenic bladder dysfunction is characterized by detrusor-sphincter dyssynergia (DSD) wherein simultaneous detrusor &urinary sphincter contractions produce high pressures in the bladder (up to 80–90 cm H2O) leading to vesicoureteral reflux (VUR) that can produce renal damage Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  14. Emergence of segmental reflex (resulting in detrusor hyperreflexia), afferent limb of which is subserved by unmyelinated c-fibres following disruption of spinobulbar pathways by spinal cord lesion. Administration of intravesicalvanilloids can alleviate symptoms through desensitization of c-fibres

  15. DSD: Definition Involuntary detrusor contractions concurrent with involuntary contraction of urethral striated muscle &/or periurethral striated muscle Karsenty G, et al. Urology. 2005; 66: 763-8.

  16. Mixed type A neurogenic bladder • The more common of the mixed type bladders: Detrusor nucleus damage renders detrusor flaccid (also referred to as detrusor areflexia), while intact pudendal nucleus is spastic producing hypertonic external urinary sphincter • Bladder is large & has low pressure, so spastic external sphincter produces urinary retention • Detrusor pressure is low so upper urinary tract damage from VUR does not occur & incontinence is uncommon Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  17. Mixed type B neurogenic bladder • Characterized by a flaccid external urinary sphincter due to pudendal nucleus lesion while bladder is spastic due to disinhibited detrusor nucleus • Thus, bladder capacity is low but vesicular pressures are usually not elevated since there is little outflow resistance • This leads to problems with incontinence, however Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  18. Lower motor neuron neurogenic bladder • Sacral micturition centers or related peripheral nerves are damaged though thoracic sympathetic nervous system outflow to lower urinary tract is intact • Bladder capacity is large since detrusor tone is low (detrusor areflexia) & internal urinary sphincter innervation is intact • Despite low detrusor pressure, overflow urinary incontinence & urinary tract infections are not uncommon Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  19. Detrusor hyperactivity with impaired bladder contractility (DHIC) • Another type of bladder dysfunction was 1st described in nursing home residents • Frequent but weak involuntary detrusor contractions causing incontinence despite incomplete bladder emptying (Resnick) • DHIC is associated with bladder trabeculation, slow bladder contraction velocity & elevated urinary residual volume after voiding attempts Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  20. Neurourological Evaluation • This evaluation is essential to assess lower urinary tract function • A full patient history should be obtained including prior genitourinary conditions/surgeries, voiding history, voiding complaints (dysuria, recurrent infections, hesitancy, nocturia, incontinence, urgency, and/or frequency) & medications • Sedative/hypnotic, antidepressant, antipsychotic, antihistamine, anticholinergic, antispasmodic, opiate, alpha adrenergic agonists/antagonists & calcium channel blocking medications may affect voiding function Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  21. Neurourological Evaluation • Optimally, a patient urinary diary with voiding pattern, fluid intake& voiding issues can help with patient evaluation and formulation of treatment recommendations • A physical examination focusing on pelvic anatomy & neurologic system is essential • Neurological examination should include mental status, reflexes, strength & sensation (including sacral dermatomes) to determine if there are neurologic conditions present that may contribute to voiding dysfunction Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  22. EAU guidelines 2013.

  23. Neurourological Evaluation • Mechanical issues such as prostate enlargement or bladder prolapse can be found on urologic exam that may impact voiding function • Issues with cognition, hand strength & coordination, joint contractures, mobility, sexuality, social/medical support & other factors may impact type of bladder rehabilitation that is feasible for a given patient • For spinal cord injured patients: Motor level of spinal lesion, whether injury is complete or incomplete, extremity tone, rectal sensation/tone, presence/absence of voluntary rectal tone & bulbocavernosus reflex should be determined Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  24. Lab Evaluation • Laboratory evaluation of neurogenic bladder patients should include: • Urinalysis • Urine culture & sensitivity • Serum BUN/creatinine & • Creatinine clearance Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  25. Postvoid residual (PVR) urine • PVR urine volume involves transurethral catheterization to measure residual urine volume in bladder immediately after voiding to determine ability of the bladder to empty completely • PVR determination should always be performed after discontinuing Foley catheterization or before instituting intermittent catheterization as part of a bladder retraining program Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  26. Postvoid residual (PVR) urine • PVRs are necessary to prevent overdistension of bladder & determine frequency of catheterization that is needed to keep residual urinary volumes under approximately 400 cc • Abnormal residual volumes have been defined by volumes greater than 100 cc or greater than 20% of voided volume & residual urine volumes under 100 cc are associated with reduced risk of development of bacterial cystitis Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  27. Ultrasound • Noninvasivemeans of determining urine post-void residual volumes, especially if precise measurement is not required Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  28. Renal clearance tests • 24-hour urine creatinine clearance & several isotope studies can be used to evaluate and sequentially follow renal function in neurogenic bladder patients • A commonly used test measures GFR via short renal clearance test using 125 I-iothalamate Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  29. Urodynamic evaluation • Urodynamic evaluation should be completed to assess urinary function, including: • Urinary flowmetry • Bladder cystometrogram/electromyogram (CMG/EMG) • Valsalva leak point pressure (LPP) measurement & • Urethral pressure profile (UPP) • Urodynamic studies are most definitive & objective means to determine abnormalities in bladder and urethra in filling/storage phase as well as voiding phase in neurogenic bladder dysfunction Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  30. Urodynamic study demonstrating detrusor instability Robert C. McDonough. HospitalPhysician. 2007; 14 Part1.

  31. Urodynamic study: Detrusor–external sphincter dyssynergia Robert C. McDonough. HospitalPhysician. 2007; 14 Part1.

  32. Urinary flow rate evaluation • Non-invasive way to quantify urinary flow, defined as volume of urine voided per unit of time • Urine flow is dependent on force of detrusor contraction as well as urethral resistance • Normal urine flow curves are bell-shaped with rapid rise to peak flow, a short duration of peak flow & then rapid falloff of urine flow • Urine flow rate patterns are not diagnostic, but high flow rates are often seen with neurogenic detrusor overactivity & poor flow rates may reflect weak detrusor pressure and/or urinary outlet obstruction Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  33. Other tests • Bladder cystometrogram/electromyogram • Urethral pressure profile (UPP) Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  34. Neurogenic Bladder Management • Management of neurogenic bladder conditions requires patient education and may include interventions such as: • Timed voiding • Manual expression • Medications • Intermittent catheterization • Indwelling urinary catheter & • Bladder and/or urethral surgical procedures Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  35. Nonpharmacologic Interventions • Bladder retraining & fluid schedule • Use of incontinence pads or external urinary collection devices • Indwelling Foley catheter placement for neurogenic bladder management is an option for uncontrollable incontinence or for urinary retention when intermittent catheterization is not practical • Suprapubic catheters have some advantages over urethral catheters including elimination of those urethral erosion risks • Individualized patient education regarding management of their neurogenic bladder via specialized nursing is important for achieving successful neurogenic bladder management Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  36. Nonpharmacologic Interventions • Nurses can monitor patient compliance with fluid schedule & teach patients how to perform timed voids as well as manual techniques including: • Self-catheterization • Credetechnique (manual pressure over suprapubic region to increase vesicular pressure to promote bladder emptying) • Tapping (over suprapubic area to trigger detrusor contraction in hyperreflexic bladders) &/or • Valsalva maneuver (which increases vesicular pressure and may also trigger detrusor contraction) Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  37. Pharmacologic Interventions • There are many different classes of drugs that are used to treat neurogenic bladder dysfunction as part of comprehensive bladder management program • Tricyclic Antidepressant Drugs • Anticholinergic (Antimuscarinic) Medications • Cholinergic Agonists • Alpha-2 Adrenergic Agonists • Alpha-1 Adrenergic Antagonists • Benzodiazepines • GABA-B Agonists Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  38. Anticholinergic (Antimuscarinic) Medications • This class of medication reduces reflex (involuntary) detrusor activity by blocking cholinergic transmission at muscarinic receptors & is 1st-line option for treating neurogenic detrusor overactivity (NDO) • Though available anticholinergic agents have similar efficacy, these drugs differ in terms of side effects & tolerability based on their muscarinic receptor selectivity and rate of drug distribution Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  39. Anticholinergic (Antimuscarinic) Medications • Anticholinergic drugs that bind M1, M2, and M3 muscarinic receptors (nonselective) have more side effects than newer agents that are more selective for M2 and/or M3 receptors • Sustained release drug preparations also improve antimuscarinic drug tolerability by attenuating peak drug serum concentrations Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  40. EAU guidelines 2013.

  41. Botulinum Toxin • Botulinum toxin blocks neuromuscular junction presynaptic vesicle fusion, which prevents acetylcholine release &thus blocks signal transmission across neuromuscular junction • It also acts on sensory afferent neurons & prevents excitatory effects of nerve growth factor (NGF) on bladder function, which may contribute to its beneficial clinical effects in treating neurogenic bladder • Injection of botulinum toxin A into bladder detrusor or external urinary sphincter produces dose-dependent weakening of those muscles, which have a high concentration of cholinergic nerve endings Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  42. Effects of BoNT‑A on detrusor smooth muscle contraction Jiang YH, et al. Nat Rev Urol. 2015; 12(9): 519-33.

  43. Botulinum Toxin • Botulinum toxin A injections can produce long-lasting improvements in neurogenic detrusor overactivity, incontinence & quality of life in spinal cord injury individuals Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  44. Botulinum Toxin • Dykstra et al. 1st reported using botulinum toxin to successfully treat urinary symptoms by injection of external urinary sphincter of spinal cord injured patients having detrusor sphincter dyssynergia • Injection of botulinum toxin A into bladder detrusor muscle to treat neurogenic incontinence was described a decade later • Botulinum toxin A injection in detrusor & suburothelialregions of bladder body can produce beneficial effects for up to 9 months, though up to 70% of neurogenic detrusor overactivity patients may require catheterization after botulinum toxin injections due to urinary retention Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  45. Botulinum Toxin • Side effects of botulinumtoxin injections are low, with a <1% risk of developing antibodies to toxin & about 1% incidence of temporary distant muscle weakness • Approximately 10% of patients do not obtain desired clinical benefit from botulinum toxin injections Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  46. Botulinum Toxin • A large, retrospective trial of 200 neurogenic bladder patients receiving detrusor botulinum toxin injections demonstrated >50% increase of mean bladder volume to 1st reflex detrusor contraction &maximum cystometric capacity, with a proportional decrease in maximum detrusor pressure • These benefits lasted more than 6 months & could be more cost effective than bladder augmentation surgery over a 5-year period if a 40% early and late complication rate of that surgery is assumed and the botulinum toxin effect lasted at least 5 months (P. Padmanabhan, et al. World Journal of Urology. 2011; 29(1): 51–57) Dorsher PT, et al. Advances in Urology. Volume 2012, Article ID 816274, 16 pages.

  47. Ahmed HU, et al. Nat ClinPract Urol. 2006; 3(7): 368-80.

  48. Ahmed HU, et al. Nat ClinPract Urol. 2006; 3(7): 368-80.

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